The guidance comes as a welcome clarification of an ongoing point of confusion for coders
Official coding guidelines instruct coders to report diagnoses that affect the plan of care. But the final interpretive guideline for the CoPs state that the individualized plan of care must include all pertinent diagnoses, further explaining that “all pertinent diagnoses” means “all known diagnoses.”
CMS’ October 2019 release of quarterly OASIS Q&As is the first time CMS has addressed the question of which guidance to follow. Questions 20 and 21 ask for clarification around whether M1021 (Primary diagnosis) and M1023 (Other diagnoses) should include all KNOWN diagnoses, or only CURRENT diagnoses.
Question 20
Question 20 asks CMS to “specifically clarify if M1021 and M1023 should include known diagnoses that are resolved or diagnoses that do not have the potential to impact the skilled services ordered.”
In the response, CMS explains OASIS guidance states agencies should include “only current diagnoses actively addressed in the [plan of care] or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself.”
CMS goes on to say that the items should exclude any resolved diagnoses or diagnoses that don’t have the potential to impact skilled services the agency provides. This is consistent with coding guidelines.
Question 21
Question 21 notes that under the Patient-Driven Groupings Model (PDGM), diagnosis grouping will be based on the claim, not the OASIS. The question goes on to ask what kinds of diagnoses can be listed on the claim.
“Any additional diagnosis listed on the claim should follow the OASIS definitions for primary and secondary diagnosis found in the OASIS Guidance Manual. Include only current diagnoses actively addressed in the plan of care or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis even if not the focus of any home health treatment itself,” CMS states in the response to Question 21.
CMS reiterates that any resolved diagnoses or diagnoses that do not have potential to impact skilled services provided by the agency should be excluded from both the OASIS and the claim, “even if they are known/documented diagnoses.”
Some Confusion Remains
Prior to the release, agencies expressed some uncertainty as to whether they should follow guidance found within the official coding guidelines and the OASIS guidance manual, or guidance found within the interpretive guidelines.
Even so, not everyone agrees that the Q&As completely resolve the issue feeling as though OASIS guidance only refers to OASIS and not the interpretive guidelines for the CoPs. So, further clarification may be needed to completely settle the question.